Thinking the (Usually) Unthinkable

After reading an article by our friend Rob MacDonald in Blue Chip magazine, and a book called Being Mortal by Harvard medical professor and surgeon Atul Gawande we started to contemplate another element of the planning cycle to consider discussing with our clients. It concerns a subject most of us don’t like to think about, but maybe it’s time we should begin to consider it as part of our future planning.

In his article MacDonald makes the comparison of financial planners, who strive to ensure that their clients are prepared for the inevitable, which is, the day we depart this life to doctors who focus on keeping people healthy and, most often, on trying to delay death.

But what most doctors and financial planners tend to avoid is a discussion on how a client would like to pass on. This has nothing to do with euthanasia, stresses MacDonald. It is rather about the fact that very often people at the end of their lives have treatments that delay the inevitable and sometimes with dramatic lifestyle and financial implications.

MacDonald cites as an example ANC stalwart Ahmed Kathrada who had a stroke at the age of 87. “As a result, he had brain surgery from which he never recovered, and died in hospital … I wonder whether a more comfortable way for him to die might not have been at home. Without treatment or surgery, surrounded by some level of familiar comfort and support. ”

Gawande, describes in his book how doctors inevitably seek to help clients avoid or evade death, almost at all costs. The problem, the author suggests, is that the doctor is not broaching the subject of how the patient would like to die, or – to reframe this – how they would like to live their last days.
Gawande quotes one person as stating: “I want to be able to eat chocolate ice-cream and watch the football on TV!” Another said: “If I cannot communicate with people, then it’s not worth it!”

What is also important is to discuss your wishes with your family members as often they are the ones called upon to make decisions on your behalf if you are unable to do so. In both cases, their families conveyed the wishes to surgeons and only gave their consent to proceed with life-threatening treatment or operations when they were assured that their loved ones would be able to eat chocolate ice cream or communicate with people. The patients didn’t make full recoveries, but they were still able to do for some time what made life worth living.

MacDonald adds: “Given that these conversations with medical professionals not only have quality of life implications, but also cost implications, as brutal as it may sound, we need to consider if this is a conversation that we as financial planners need to have with clients. But the conversations are neither comfortable nor easy. The challenge is how to have them in the first place. A first step to having these conversations may be to introduce a broader life planning approach to the work of financial planning.”

Ultimately people should be encouraged to make choices about how they would like to be treated in the event of serious or terminal illness or injury. Further research indicates that an increasingly popular way of doing this is by drawing up an Advance Care Plan (ACP).

According to the American National Institute on Aging an ACP is not just about old age. “At any age, a medical crisis could leave you too ill to make your own healthcare decisions.”

Wider choices in medical care are also emerging in our country. An example is Cape Town-based Chariot Health, which has revived the bygone practice of the doctor’s home visit by focusing exclusively on home care through a network of medical practitioners in different disciplines. They are therefore able to provide holistic care in the home, including specialised services such as cancer, palliative and geriatric care, as well as provide assistance and advice in drawing up an ACP.

Ultimately the goal of ACP is to help ensure that people receive medical care that is consistent with their values, goals, and preferences. Growing numbers of health care providers are encouraging people to consider options such as an ACP and to document their wishes and preferences. They can then explore with their financial planners ways in which to accommodate these.

Regardless of the clinical scenario, ACP should be proactive, appropriately timed, and integrated into routine care and future planning.